Working Diagnosis:
Left Scapular Body Fracture

Treatment:
Injury was initially managed using shoulder sling for 2 weeks with intermittent range of motion while at home.

Outcome:
At the 2 week follow up visit, CT was obtained. In the interim, the patient had improved pain but slightly decreased ROM and strength. Physical therapy was prescribed twice weekly for 6 weeks for increased ROM and
mobility. At the 2 month visit, he had regained full mobility without evidence of scapulothoracic or glenohumeral dysfunction.

Editor's Comments:
This is a unique case of a scapular fracture due to direct trauma to the posterior shoulder. Most scapular fractures occur with an energy vector directed from lateral and cephalad to the shoulder. Having an isolated scapular fracture is also less common, with roughly 90% of scapular fractures having concomitant injuries, mostly additional thoracic spine and ipsilateral upper extremity injuries.
While plain radiographs including AP shoulder, axillary, and scapular Y views are appropriate for these injuries, additional cervical spine and chest views are often necessary to rule out associated injuries. As demonstrated in this case, three-dimensional (3D) CT scan is the study of choice for measuring displacement, angular deformity, glenohumeral articular involvement, and clinical suspicion for fracture with initial negative radiographs.
Nondisplaced and most minimally displaced fracture can be managed non-operatively as demonstrated in this case, though degree of displacement should be monitored closely for progression in the initial weeks of recovery. Typical return to full activity is 12 weeks.
Surgical criteria are more controversial, typically based on displacement, angulation, shortening, and articular extension. In surgical management, early post-operative range of motion is promoted, and ultimate return to normal activities is similar to non-surgical patients, around 12 weeks after surgery.

References:
1.Cole, P.A., Freeman, G. & Dubin, J.R. Scapula fractures. Curr Rev Musculoskelet Med 6, 79 87 (2013). https://doi.org/10.1007/s12178 012 9151 x1.
2.Baldwin KD, Ohman Strickland P, Mehta S, Hume E. Scapula fractures: a marker for concomitant injury? A retrospective revi ew of data in the National Trauma Database. J Trauma. 2008.
3.Berritto D, Pinto A, Russo A, et al. Scapular fractures: a common diagnostic pitfall. Acta Biomed . 2018;89(1 S):102 110. Published 2018 Jan 19. doi:10.23750/ abm . v89i1 S.7014
4.Ideberg R, Grevsten S, Larsson S. Epidemiology of scapular fractures. Incidence and classification of 338 fractures. Acta Orthop Scand. 1995 Oct;66(5):395 7.
5. Cole, Peter A. MD; Gauger, Erich M. MD; Schroder, Lisa K. BS, MBA Management of Scapular Fractures, Journal of the American Academy of Orthopaedic Surgeons: March 2012 - Volume 20 - Issue 3 - p 130-141
doi: 10.5435/JAAOS-20-03-130.

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